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• Doctor-patient relationship

  A unique social relationship where bonding is planned with the ultimate objective of assisting the patient to achieve treatment goals
• Doctor's role in the doctor-patient relationship

  • Take on the responsibility of directing, effecting and maintaining the therapeutic relationship, exhibiting a professional and ethical approach
• The patient-physician relationship is fundamental for providing excellent care, to the healing process, and to improved outcomes
• Parsons' "Ideal Patient" (Sick Role)


  Rights: Give up some activities and responsibilities, regarded as being in need of care and unable to get well by their own decisions<|>Obligations: Must want to get better quickly, seek help and cooperate with a doctor
• Parsons' "Doctor" (Doctor's Role)

  Apply a high degree of skill & knowledge to the problems of illness, act for welfare of patient and community rather than for own self interest, be objective and emotionally detached, be guided by rules of professional practice
• Doctor's rights

  Granted right to examine patients physically & to enquire into intimate areas of physical & personal life, granted considerable autonomy in professional practice, occupies position of authority in relation to the patient
• Types of doctor-patient relationship

  • Physician control (Low)
  • Physician control (High)
  • Patient control (Low)
  • Patient control (High)
  • Mutuality
• Paternalism

  The traditional form of doctor-patient relationship, with a passive patient and a dominant doctor
• Advantages of paternalism

  • The supportive nature appears more important when patients are very sick, relief from the burden of worry is curative in itself, the trust and confidence implied allow doctors to perform "medical magic" (placebo effect)
• Disadvantages of paternalism

  • Manipulation and exploitation of the vulnerable and ill
• Mutuality

  The optimal doctor-patient relationship model, based on communication where each participant brings strengths and resources
• Patient's role in mutuality

  Patients need to define their problems in an open and full manner, have the right to seek care elsewhere when demands are not satisfactorily met
• Doctor's role in mutuality

  Physicians need to work with the patient to articulate the problem and refine the request, have the right to withdraw services formally from a patient if they feel it is impossible to satisfy the patient's demand
• Advantages of mutuality

  • Patients can fully understand what problem they are coping with through physicians' help, physicians can entirely know patient's value, decisions can easily be made from a mutual and collaborative relationship
• Disadvantages of mutuality

  • If the communication is fake, both physicians and patients do not have mutual understanding, making decision is overwhelming to a patient
• Consumerism

  Reverse of the very basic nature of the power relationship, with the patient taking an active role and the doctor adopting a fairly passive role
• Patient's role in consumerism

  Health shoppers, indications of consumer behavior: cost-consciousness, information seeking, exercising independent judgement
• Doctor's role in consumerism

  Health care providers, technical consultant, to convince the necessity of medical services
• Advantages of consumerism

  • Patients can have their own choices
• Disadvantages of consumerism

  • When things seem to go wrong, when satisfaction is low, or when a patient suspects less than optimal care or outcome, patients are more likely to question physician authority
• Consultation styles

  • Doctor centered (paternalistic) - doctor is the expert and patient expected to cooperate, dominates the consultation, tightly controlled interviewing style aimed at reaching an organic diagnosis, asks direct, closed questions, 'voice of medicine' - focus on biomedical diagnosis and treatment as quickly as possible, rejects the patient's ideas, evades the patient's questions
  • Patient centered (mutuality) - less authoritarian, encourages patient to express their own feelings and concerns, asks open questions, actively listens, 'voice of the patient' - communication of patients beliefs, feelings & psychosocial context (bio psychosocial), challenges and reflects the patient's words and behaviour to allow them to express themselves in their own way
• Key aspects of a patient-centred consultation

  • Biopsychosocial perspective, patient-as-a-person, sharing power and responsibility, therapeutic alliance, doctor-as-a-person
• Influences on the doctor-patient relationship

  • Influence of time - average time varies by specialty, pressures of time - doctor centered consultation, patient centric approach needs more time but reduces total consultation time
  • Patient characteristics and behaviours - patient's ability to exercise control depends on age, social and educational level, sex, different languages
• In the past, the doctor-patient relationship was characterized by paternalism, as doctors had higher social status and their advice was seen as a paramount mandate
• At present, the doctor-patient relationship is characterized by consumerism and mutuality, as patients have higher education and better economic status, and the concept of patient autonomy and ability to question doctors has increased
• Health literacy


  The ability to obtain, process, and understand basic information and services needed to make appropriate health decisions. Low health literacy reduces the success of the doctor-patient relationship.
• Pressures

  • Time-doctor centered consultation
• Doctor's own style & approach

  Influences the time available
• Patient centric approach

  Needs more time but overall reduces the number of return visits and thus the total consultation time
• Patient characteristics and behaviours

  • Age
  • Social and educational level
  • Sex
  • Different languages
• Patient's ability to exercise control

  Depends on a number of factors
• Paternalism

  Physicians in the past were people who had higher social status, "Doctor" is seen as a sacred occupation which saves people's lives, The advices given by doctors are seen as paramount mandate
• Consumerism and mutuality

  Patients nowadays have higher education and better economic status, The concept of patient's autonomy, The ability to question doctors
• Health literacy

  The ability to obtain, process, and understand basic information and services needed to make appropriate health decisions, Low health literacy reduces the success of treatment and increases the risk of medical error, Health literacy is of continued and increasing concern for health professionals, as it is a primary factor behind health disparities
• Tests to identify health literacy

  • Medical Term Recognition Test (METER)
  • Rapid Estimate of Adult Literacy in Medicine (REALM) test
  • The Short Assessment of Health Literacy in Spanish and English populations (SAHL-S&E)
  • The Critical Health Competence Test (CHC-Test)
• Teach back method

  Intervention to improve health literacy, "Ask Me 3" is designed to bring public and physician attention to this issue, by letting patients know that they should ask three questions each time they talk to a doctor, nurse, or pharmacist: What is my main problem? What do I need to do? Why is it important for me to do this?
• Paternalist model


  The doctor, as medical expert, is solely responsible for treatment decisions with the patient expected merely to cooperate with advice and treatment
• Shared decision-making

  Both doctor and patient are involved in the decision-making process, Both parties share information, Both parties take steps to build a consensus about the preferred treatment, An agreement (consensus) is reached on the treatment to implement
• Informed model

  Partnership between doctor and patient - division of labour, Doctor - information on all relevant options, Decision-making- patient
• Impetus for shared decision making

  • Increased medical knowledge among patients
  • Prevailing social values- individual autonomy and responsibility
  • Chronic illness to make choices between the treatment options and to balance risks & benefits -medical uncertainity
  • Doctors make inaccurate guesses about patients concerns & their preferences and treatment choices differ